ConnectorCare Eligibility & Enrollment MLRI Basic Benefit - - PDF document

ConnectorCare Eligibility & Enrollment

MLRI Basic Benefit Training February 27, 2020 Suzanne Curry Co-Director, Policy & Government Relations Health Care For All scurry@hcfama.org

• Insurance through private HMO plans with the government

helping pay for much of the costs of coverage

• You can only get it from the Massachusetts Health

Connector.

What is ConnectorCare?

Role of the Health Connector

• Health insurance “marketplace” for certain private

health insurance plans

• Decides who qualifies for government assistance

to lower costs for insurance plans

• Sets rules for state individual mandate

Health Connector Locations

• Main office Boston
• Walk-In Centers

– Boston – Brockton – Springfield – Worcester

• Customer Service Phone Number:

1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773)

• Website: www.mahealthconnector.org

Individual Coverage

• Subsidized health coverage
• ConnectorCare for those with income of 300% FPL
• r less
• Premium discount for those 300-400% FPL
• Unsubsidized health plans
• Stand-alone dental plans

Health Connector for Business

• Health & dental plans for small employers who want to
• ffer insurance to their employees

Health Connector Offerings

• U.S. Citizen, national or lawfully present immigrant
• Resident of Massachusetts
• Not incarcerated

Who can use Health Connector?

Who can qualify for help with costs

• Financially eligible
• Not eligible for or enrolled in other

health coverage

• Will file a federal tax return
• Will not file as married filing separately

unless reason is domestic violence or abandonment Why tax filing matters

• Help with premium cost is from Advance Premium Tax

Credit (APTC)

• Based on estimated annual tax income for the year
• Paid in advance by US Treasury directly to insurance

company each month

• Must file taxes for year in which APTC received

– Must “reconcile” advanced credit based on estimated income with actual credit due based on actual income on tax return

Financial eligibility for APTC

• Income 400% FPL or less for APTC only (discount on

premium)

• Income 300% FPL or less for ConnectorCare (affordable

coverage)

• Income at least 100% FPL unless

– Lawfully present non-citizen is not eligible for MassHealth due to immigration status – Even though income under filing threshold, APTC creates tax filing obligation

Modified Adjusted Gross Income

• Household includes tax filers & tax dependents
• Income is expected annual “adjusted gross income” on

federal tax return plus

– Nontaxable Social Security Income – Nontaxable Interest Income – Nontaxable Foreign Income

• Tax dependents’ income doesn’t count unless high

enough to require filing a return

– Earnings over $12,000 for the year requires a return – Nontaxable Social Security & child support not counted

• Not eligible for Medicaid (except MassHealth Limited) or

enrolled in Medicare Part A

• Not eligible for affordable Employer-Sponsored

insurance

• “Affordable” ESI means that your plan:

– Costs less than 9.78% (2020) of family income for individual/employee-only plan

• “Family glitch”: affordability of ESI for family member

based on cost of self-only plan, not cost of family plan

No other coverage

• APTCs & added state-funded subsidies to keep costs

low

• No deductibles
• No premium contribution options if income 150%

FPL or less

• Copays vary by income level with 3 income tiers
• Family income ≤ 300% FPL
• Can only choose from a subset of plans offered by

Connector as ConnectorCare plans

ConnectorCare

• AllWays Health Partners

(formerly Neighborhood Health Plan)

• Boston Medical Center (BMC) HealthNet Plan
• Fallon Health
• Health New England
• Tufts Health Plan Direct

Must select plan within 60 days of eligibility determination

ConnectorCare Plans (2020) ConnectorCare Premiums

Plan Type FPL range Monthly premium Plan Type 1 0-100% FPL $0/mo Plan Type 2A 100.1-150% FPL $0/mo Plan Type 2B 150.1-200% FPL $45/mo Plan Type 3A 200.1-250% FPL $87/mo Plan Type 3B 250.1-300% FPL $130/mo

Lowest cost premiums for 2020

ConnectorCare Benefits & Co-pays

• Must affirmatively select a plan to enroll
• Higher premium for some ConnectorCare HMO choices

based on provider networks but benefits the same

• Deadlines to enroll & pay first month’s premium (if there

is a premium)

• by the 23rd of the month for coverage effective the

1st of the next month

• after the 23rd, coverage not until the 1st of the

following month

Plan selection & Premium Payments

• Only time individuals & families can enroll in Health

Connector plan or change plans without a “qualifying event”

• Open Enrollment for 2020 coverage ran from

November 1, 2019-January 23, 2020

• January 24, 2020-October 31, 2020– cannot enroll for

2020 without a “qualifying event”

• Qualifying event (QE) allows for “special enrollment

period” (SEP)

Open Enrollment ConnectorCare Qualifying Event

• Being newly eligible for ConnectorCare is a

Qualifying Event

– Applies automatically if this is first time you have qualified for ConnectorCare – If previously eligible for ConnectorCare & failed to enroll, unable to enroll until next open enrollment unless some other Qualifying Event occurs

Eligible but Unable to Enroll

• Can apply at any time, but if it is outside of Open

Enrollment and…

– You are not newly eligible for ConnectorCare & – You don’t claim any other Qualifying Event

• Decision will say you are eligible but not able to enroll

– Need to claim Qualifying Event or ask for waiver to enroll

• Must identify Qualifying Event
• Helpful Q E for those eligible for ConnectorCare who did not enroll

by deadline

– Mistakenly enrolled or did not enroll in a Health Connector health or dental plan due to an error, misrepresentation, or inaction on the part of the Health Connector or an enrollment assister – Good cause waiver available from Office for Patient Protections

• See materials online for more on Qualifying Events & Special Enrollment

Periods

Helping eligible not able to enroll

• People who are eligible for ConnectorCare are also

eligible for time-limited Health Safety Net (HSN) – HSN eligibility ends 90 days from date of eligibility notice – After 90 days, people qualify for HSN dental only

• People who are eligible for ConnectorCare and do not

enroll in a health plan still lose HSN after 90 days

• Watch out for erroneous approval of ConnectorCare for

undocumented immigrants—it will result in loss of HSN!

Health Safety Net & ConnectorCare Newborn to Mother on ConnectorCare

• Having a newborn is a qualifying event BUT
• If family income is ≤300% FPL & newborn is

eligible for MassHealth, baby will not be eligible for ConnectorCare

– Newborn will not automatically get MassHealth unless mother had MassHealth Limited + ConnectorCare – Otherwise, newborn’s MassHealth coverage goes back 10 days prior to report of birth

• Report Birth ASAP!

• 90-day grace period, but:

– If all premiums owed are not paid within 90 days, coverage is terminated retroactively to the first unpaid month

• Health Connector has process to apply for premium

hardship waivers

– Request form through Customer Service – Grounds include:

– Homeless – Shut-off notice – Significant, unexpected increase in essential expenses (e.g. due to domestic violence, death of spouse; new caretaking responsibilities; household/personal damage cause by fire, flood, natural disaster) – Filed for bankruptcy

Non-Payment of Premiums Key Differences from MassHealth

• Differences in MAGI income calculation & household

rules

• Higher upper income limit with premiums & copays

varying by income level

• More liberal immigrant eligibility rules for adults

– E.g. No 5 year bar for adult green card holders

• Tax filing requirement
• Requirement of no other coverage
• Must take action to enroll; no automatic enrollment
• May be eligible but unable to enroll in some situations
• No dental; no non-emergency medical transportation

Troubleshooting

• Refer clients to enrollment assisters-they are trained

to help

• Call Connector Customer Service

– Escalate to Consumer Ombudsman

• Appeal Connector decisions to Connector Appeals

Unit

– Information included with notice of decision

• Appeal health plan decisions:

– 1st to plan itself – If unresolved, then to Office of Patient Protection (same process as commercially insured)

Case Example: Mila & José

• Mila and her husband José

– have 2 children – earn about $60,000/year (just over 200% FPL) – are not offered health insurance through their jobs What coverage are Mila and José eligible for? What coverage are the children eligible for?

Thank you! Questions?